Nokea
A client with an ileal conduit reports skin irritation around the stoma. What should the nurse recommend?
- A. Apply a skin barrier cream.
- B. Use adhesive tape to secure the appliance.
- C. Clean the area with alcohol.
- D. Change the appliance daily.
Correct Answer: A
Rationale: A skin barrier cream protects the peristomal skin from urine irritation, promoting healing and preventing further breakdown.
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A nurse is caring for a client with an ileal conduit. When assessing the stoma, which of the following outcomes are undesirable? Select all that apply.
- A. Dermatitis.
- B. Bleeding.
- C. Fungal infection.
- D. Flow of adhesive solvent into the stoma.
- E. Partial obstruction of the stoma from skin cement.
Correct Answer: A,B,C,D,E
Rationale: Dermatitis, bleeding, fungal infections, adhesive solvent flow, and partial obstruction are all undesirable as they indicate complications such as skin irritation, trauma, infection, or improper appliance application that can impair stoma function or client health.
The nurse is reviewing the chart of a 55-year-old male client who is scheduled for a lumbar laminectomy. The nurse should report which of the following to the surgeon?
- A. Pimple on the lower back.
- B. Abnormal electrocardiogram (ECG).
- C. Hearing aid.
- D. Allergy to iodine.
Correct Answer: B
Rationale: An abnormal ECG indicates potential cardiac issues that could affect surgical safety under anesthesia. This must be reported to the surgeon for further evaluation. A pimple, hearing aid, or iodine allergy, while notable, are less immediately critical unless directly related to the procedure.
A client is scheduled for an arteriogram. The nurse should explain to the client that the arteriogram will confirm the diagnosis of occlusive arterial disease by:
- A. Showing the location of the obstruction and the collateral circulation
- B. Scanning the affected extremity and identifying the areas of volume changes
- C. Using ultrasound to estimate the velocity change in the blood vessels
- D. Determining how long the client can walk
Correct Answer: A
Rationale: An arteriogram involves injecting contrast dye to visualize arteries, revealing the location of obstructions and collateral circulation in occlusive arterial disease. It is a direct imaging method, unlike ultrasound (velocity changes) or volume scans, and walking duration is not assessed.
The nurse is caring for a client whose condition has been deteriorating. The client becomes unresponsive, the blood pressure is 80/40, and SpO2 is 90% on 50% face mask. The nurse should:
- A. Begin chest compressions.
- B. Call the rapid response team.
- C. Remove the family from the room.
- D. Ventilate the client with an ambu bag.
Correct Answer: B
Rationale: Unresponsiveness, hypotension, and low SpO2 indicate a critical condition. Calling the rapid response team ensures immediate multidisciplinary intervention.
A client 2 days ago. What should the nurse include in the client's plan of care? Select all that apply.
- A. When using a walker, encourage the client to point the toes inward.
- B. Position a pillow between the legs to maintain abduction.
- C. Allow the client to be in the supine position or in the lateral position on the unoperated side.
- D. Do not allow the client to bend down to tie or slip on shoes.
- E. Place ice on the incision after physical therapy.
Correct Answer: B,C,D,E
Rationale: Positioning pillows for abduction, appropriate positioning, avoiding bending, and applying ice promote healing and prevent dislocation. Pointing toes inward is incorrect.